The Frozen Shoulder: What's Diabetes Got to Do With It?

Adhesive casulitis, also known as frozen should, is a rheumatic condition which can leave you unable to reach above your head or behind your back. It results from inflammatory changes in the connective tissue of an area called the shoulder capsule. Over time, the tissue can thicken and become tight. Stiff bands of tissue called adhesions develop, making movement of the joint painful and even blocking the shoulder joint’s normal range of motion.

Eventually the shoulder becomes extremely stiff and extremely painful to move, as if it’s “frozen” in place. If you wear an insulin pump, this condition can be especially challenging.

DiabeticLifestyle Editorial Board Member Amy Hess Fischl, MS, RD, LDN, BC-ADM, CDE says she’s worked with several type 1 women diagnosed with frozen shoulder. “One of my patients who had long used an insulin pump, had to switch back to insulin injections until her shoulder issue resolved since inserting infusion sets was too difficult,” Hess Fischl explained. “Fortunately, she was able to resume her insulin pump after several months of regular physical therapy but in the interim more frequent communication was required between us to help her adjust her insulin doses to account for the pain, reduced sleep and less activity.”

There are two types of adhesive capsulitis.In the first, there is no direct explanation for the condition and pain and stiffness come on so gradually that you may not notice it until it interferes with your daily activities. The second type is caused by some kind of trauma, such as a fall, where pain and stiffness does not disappear over time.

Who Is At Risk?

About three percent of the general population get frozen shoulder, compared to about 20% of people with insulin-dependent and non-insulin dependent diabetes and in those with prediabetes. Women are more likely to develop the condition than men, and it mainly affects people between the ages of 40-65.Although there is no conclusive link to high sugars or insulin use, long-term complications of diabetes may include changes in the connective tissue that occur as a result of high glucose levels.

People who have a history of adhesive capsulitis are at an increased risk to develop the condition on the other side of the body. Recurrence on the affected side is also possible, particularly in patients with diabetes.

According to Dr. John M. Vasudevan, MD, assistant professor of clinical physical medicine and rehabilitation and assistant professor of orthopedic surgery in the Perelman School of Medicine at the University of Pennsylvania, there may be a genetic predisposition for the condition, but evidence for this is unclear.

What Are The Symptoms?

The condition causes progressive pain, stiffness, limited activity and passive range of motion of the shoulder joints, and night pain. The pain is often described as a poorly localized, dull ache or if localized, in the area of the shoulder capsule. Pain can radiate down the biceps, and be significant enough to disturb sleep.

Adhesive capsulitis is often described as having three stages: a painful stage, a frozen stage, and a thawing stage. But the American Family Physicians’ guide to treating adhesive capsulitis notes that there is little evidence for this sequential progression. Pain and loss of range of motion can occur throughout the condition, and often lasts for one to two years.

How Is It Diagnosed?

Your doctor will take a thorough shoulder history to determine if there has been an injury and perform a physical exam. Because the diagnosis is often one of exclusion, she may also order x-rays of the shoulder to determine that there is no other problem, such as osteoarthritis.

An MRI exam is better for soft tissue problems such as a rotator cuff issue and may reveal inflammation, but imaging tests do not show specific signs to diagnose frozen shoulder.

What Is The Treatment?

There are a number of treatments for adhesive capsulitis.

Early and active treatment is recommended by the American Family Physicians. Care should be taken to prevent the shoulder from remaining immobile.

“Even if there is a small remaining difference in range of motion, it is rarely enough to hinder activity of daily living,” says Dr. Vasudevan. “The bad news is that it can take from 6 months to two years to achieve complete recovery.”

Since corticosteroids can raise glucose levels, injections may be limited for people with diabetes.

“For people with diabetes, particularly those who are insulin dependent or with poor glycemic control, a cortisone shot can potentially cause a spike in blood sugar in the first several days after injection,” says Dr. Vasudevan. “I would strongly recommend that an injection be performed with image guidance—ultrasound or fluoroscopy—to accurately deliver the medication into the deep shoulder joint. This not only maximizes the amount of steroid distributed to the painful region, but minimizes the amount that can be absorbed into the bloodstream and cause elevation in blood glucose.”

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If there has been no improvement with nonsurgical treatment after two months, surgery may be recommended.

One surgical approach involves manipulation of the shoulder while a patient is under anesthesia, where the surgeon forces the shoulder to move and causes the joint capsule to tear or stretch.

“Manipulation Under Anesthesia (MUA) is used for difficult cases and not required for most people who suffer the condition,” says Dr. Vasudevan. “Anesthesia is required for the pain, and to allow muscles to adequately relax, which allows for greater range of motion during the manipulation.”

While forcing the joint through and beyond its range of motion can temporarily exacerbate inflammatory pain in the shoulder “this is acceptable if the shoulder range of motion can be increased as a result,” the doctor explains.

A second surgical option is arthroscopic surgery, where several small incisions are made in and around the shoulder. A small camera helps the surgeon to see instruments inserted through the incisions. The instruments cut through the joint capsule’s tight portions, allowing the shoulder to move. In many cases, both types of surgery are used to obtain the best results.

After surgery you may receive pain blocks or shots so physical therapy can be performed.

What Is The Prognosis?

Treatment with physical therapy and NAISDs often restores motion and function of the shoulder within a year. Left untreated, the shoulder may heal in two years. For about 10% of patients, however, the condition never fully disappears.

After surgery restores range of motion, you must continue physical therapy for several weeks or months to prevent frozen shoulder from returning.

How You Can Prevent Frozen Shoulder?

“Unfortunately, there is very little information on how to prevent frozen shoulder,” said Dr. Vasudevan. “Many cases are without cause. People with diabetes may have an elevated risk, but there are so many known causes that it is definitely hard to pin the problem to diabetes itself.”

One risk factor, however, is to avoid the temptation to reduce use of the shoulder after sustaining an injury. “If you sustain an injury keep moving and using the shoulder as much as much as you can tolerate: use it or lose it!” says Dr. Vasudevan.